Impact of Medicaid and Medicaid Managed Care Presented to: - - PowerPoint PPT Presentation

Impact of Medicaid and Medicaid Managed Care

Presented to: Mississippi Senate Medicaid Committee February 19, 2020

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Economic Impact of Mississippi Hospitals

• Mississippi hospitals employ over 61,000 individuals
• Mississippi hospitals help create over 119,000 jobs
• Mississippi hospitals provide direct salaries and

wages of over $8 billion

• Mississippi hospitals directly and indirectly provide

total salaries and wages of over $15 billion

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Mississippi Hospitals and Extended Hospitals

• In addition to the specialized services provided at
• ur larger trauma hospitals such as UMC, North MS,

Forrest General and Memorial Gulfport, out‐of‐state hospitals also serve Medicaid patients

• Regional One Health in Memphis, Univ. of South

Alabama in Mobile and Ochsner in New Orleans are significant providers of hospital services.

• Methodist Le Bonheur – almost half of the babies in

the NICU were from Mississippi.

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Holding the Line on Expenses

• Mississippi non‐profit hospitals have the lowest

national inpatient per diem expenses ‐ $1,365/day.

• Mississippi state and local government hospitals

have the 8th lowest national inpatient per diem expenses ‐ $1,239/day.

• Mississippi for profit hospitals have the 12th lowest

national inpatient per diem expenses ‐ $1,762/day.

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Community Benefits

• Alzheimer’s Walk (Memorial Hospital at Gulfport)
• Community Lunch and Learn (Gilmore Memorial Hospital)
• Heart Health & Wellness Awareness (Bolivar Medical Center)
• Relay for Life (North MS Health Services)
• Free Pain Management Clinic (Covington County Hospital)

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Community Benefits

• Free Skin Cancer Screening, MS Support Group (Anderson

Regional Medical Center)

• Student Ambassador Leadership Program (Forrest General Hospital)
• Children’s Health & Safety Fair (Greenwood Leflore Hospital)
• Diabetes Management Classes and Relay for Life (Lawrence

County Hospital)

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Community Benefits

• National Alliance on Mental Health (Anderson Regional Medical Center)
• Distinguished Young Woman Scholarship Pageant

(Lackey Memorial Hospital)

• My Preemie & Me Event (Delta Regional Medical Center)
• American Legion Post #200’s Salute to Veterans (Greenwood

Leflore Hospital)

• Community Health Fair (Covington County Hospital)

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Fiscal Challenges for Mississippi Hospitals

• Reductions in Medicare Inpatient and Outpatient

Marketbasket Increases through 2027 ‐ $3 Billion

• Medicare DSH and Sequestration and Other Cuts

Projected Through 2027 ‐ $1.7 Billion

• Since 2010, 6 hospital closures – Belzoni, Kilmichael,

Natchez, Newton, Marks, Senatobia

• Since 2010, 6 hospital bankruptcies – Natchez,

Clarksdale, Batesville, Aberdeen, Amory, Magee

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Important Events

• Medicaid Adopts DSH and UPL programs, 1990s
• Hospital Provider Tax Codified, 2009
• Outpatient MississippiCAN (Managed Care), 2011
• Mississippi Medicaid DRGs and APCs, 2012
• Inpatient MississippiCAN (Managed Care) and FFS

UPL program eliminated, 2015

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Mississippi Hospitals ‐ Payer Mix Q1‐3, 2019

Blue Cross Blue Shield ‐ 15.49% Other ‐ 3.73% Commercial Insurance ‐ 13.06% Medicaid FFS ‐ 5.04% Magnolia Health ‐ 7.19% Molina Healthcare ‐ 2.14% United Healthcare ‐ 5.71% Self Pay ‐ 10.10% Medicare ‐ 31.63% Medicare Advantage ‐ 5.92%

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Provider Taxes By Mississippi Hospitals

• For SFY 2020, Mississippi hospitals will pay the

entire state share for hospital access payments, $122,190,418 to receive $527,364,770.

• For SFY 2020, Mississippi hospitals will pay the

entire state share for Disproportionate Share Hospital Payments, $53,328,509 to receive $231,661,637.

• For SFY 2020, Mississippi hospitals will pay an

additional $100,878,125 to support the state share used for hospital payments.

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Hospitals – Medicaid Inpatient SFY 2013‐18

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648,729,141 671,151,312 658,486,490 580,915,145 576,019,642 600,662,599 520,000,000 540,000,000 560,000,000 580,000,000 600,000,000 620,000,000 640,000,000 660,000,000 680,000,000 2013 2014 2015 2016 2017 2018

Medicaid Inpatient Visits

• Normal Newborn
• Prematurity
• Psychoses
• Bronchitis / Asthma
• Delivery w/o Comp. Diagnosis • Red Blood Cell Disorder
• Neonate with Sig. Problems
• Septicemia
• C‐section
• Behavioral Disorders

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Hospitals – Medicaid Outpatient SFY 2013‐18

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278,613,836 274,754,394 327,527,599 366,734,630 407,653,121 419,523,868 ‐ 50,000,000 100,000,000 150,000,000 200,000,000 250,000,000 300,000,000 350,000,000 400,000,000 450,000,000 2013 2014 2015 2016 2017 2018

Medicaid Outpatient Visits

• Respiratory Infections
• Back Pain
• Pharyngitis
• Viral Infection
• Fever
• Hypertension
• Abdominal Pain
• Chest Pain
• Headaches
• Dental Caries

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Hospitals – Medicaid Total Claims SFY 13‐18

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927,342,977 945,905,706 986,014,089 947,649,775 983,672,763 1,020,186,467 880,000,000 900,000,000 920,000,000 940,000,000 960,000,000 980,000,000 1,000,000,000 1,020,000,000 1,040,000,000 2013 2014 2015 2016 2017 2018

Medicaid and Medicaid Managed Care

• Admin. Costs for MCOs exceed $1.3B since 2011
• SFY 2019 total program admin approx. $400M
• $750M for SFY 2011 direct state appropriation

June 2011 enrollment: Total – 707,450; MCO < 200,000

• $931M for SFY 2020 direct state appropriation

December 2019 enrollment: Total ‐ 715,815; MCO ‐ 438,029

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Hospital Issues with Medicaid Managed Care

• Claims rejected b/c providers were not loaded into

payer’s system; after providers correctly loaded, claims were resubmitted and were denied as untimely

• Claims denials as a result of failure to properly load

new CPT codes – took 5 months to resolve in 2017 and 4 months to resolve same issue in 2018

• Implemented an ER level reduction policy in July

2019; but, tried to recoup claims dating back to 2018. Recoupment was significantly reduced after appeal.

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Hospital Issues with Medicaid Managed Care

• Ongoing challenges enrolling mothers and babies in

the same MCO

• MCO incorrectly configured certain surgical codes

causing codes to underpay

• MCO system configuration issue caused claims to

deny as non covered services – issues resolved after 10 months

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Hospital Issues with Medicaid Managed Care

• Revenue Code 204 behavioral health claims were

incorrectly routed by MCO to its medical claims payer from behavioral health sub and claims denied – 28 mo.

• MCO incorrectly loaded wrong NPI number which

caused claims to process as out of network. MCO then tried to recoup the correctly paid claims which required an appeal.

• MCO credentialing issues and delays in physician and

provider credentialing

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HEDIS Measures for Mississippi MCOs

Magnolia – Consumer Satisfaction – Overall 4.5 Prevention – Overall 2.0 Children and Adolescent Well Care – Overall 1.5 Dental Visits – 5.0 Childhood Imm. Combo 10 by age 2 – 1.0 Adolescent Imm. Combo 2 by age 13 – 1.0 BMI Percentile Assessment ages 3‐17 – 2.0 Women’s Reproductive Health – Overall 3.0 Prenatal Checkups – 3.0 Postpartum Care – 2.0

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HEDIS Measures for Mississippi MCOs

United – Consumer Satisfaction – Overall 3.0 Prevention – Overall 2.0 Children and Adolescent Well Care – Overall 2.0 Dental Visits – 5.0 Childhood Imm. Combo 10 by age 2 – 2.0 Adolescent Imm. Combo 2 by age 13 – 1.0 BMI Percentile Assessment ages 3‐17 – 1.0 Women’s Reproductive Health – Overall 3.5 Prenatal Checkups – 4.0 Postpartum Care – 3.0

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HEDIS Measures for Mississippi MCOs

Magnolia ‐ Treatment – Overall 2.0 Asthma – Overall 3.0 Asthma Control – 5.0 Asthma Drug Management – 1.0 Diabetes – Overall 2.0 Blood Pressure Control – 2.0 Eye Exams – 3.0 Glucose Control – 2.0 Patients received statin therapy – 1.0 Patients statin adherence – 1.0

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HEDIS Measures for Mississippi MCOs

United ‐ Treatment – Overall 2.0 Asthma – Overall 2.5 Asthma Control – 4.0 Asthma Drug Management – 1.0 Diabetes – Overall 2.0 Blood Pressure Control – 2.0 Eye Exams – 4.0 Glucose Control – 2.0 Patients received statin therapy – 2.0 Patients statin adherence – 1.0

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HEDIS Measures for Mississippi MCOs

Magnolia – Mental and Behavioral Health – Overall 2.5 Depression: Adhering to medication 6 mo. – 1.0 Follow up after hospitalization – 3.0 Follow up after ED visit – 2.0 Follow up after ED for alcohol / drug abuse ‐ 1.0 Alcohol or drug abuse treatment engaged – 2.0 Continued follow up after ADHD diagnosis – 5.0 Diabetes screening for schizophrenia / bipolar – 1.0 Adherence to antipsychotic meds for schizophrenia – 2.0 Cholesterol/sugar testing for youth on antipsych meds ‐ 2.0

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HEDIS Measures for Mississippi MCOs

United – Mental and Behavioral Health – Overall 2.0 Depression: Adhering to medication 6 mo. – 1.0 Follow up after hospitalization – 3.0 Follow up after ED visit – 2.0 Follow up after ED for alcohol / drug abuse ‐ 2.0 Alcohol or drug abuse treatment engaged – 2.0 Continued follow up after ADHD diagnosis – 4.0 Diabetes screening for schizophrenia / bipolar – 1.0 Adherence to antipsychotic meds for schizophrenia – 2.0 Cholesterol/sugar testing for youth on antipsych meds ‐ 1.0

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Medicaid Supplemental Payments

• CMS Transition from Directed Payments
• Restructuring Payments to Protect Rural Hospitals
• What happens to DSH?
• Maximizing Benefits of Supplemental Payment

Programs (Physician UPL, Physician Directed Payments)

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Recommendations

Governor’s Rural Health Task Force Recommendations

• MDOM change its CCO agreements to align with

Mississippi law and stringently enforce timely payment contract requirements

• MDOM establish a collaborative work group with key

stakeholders to monitor and reconcile claim payment errors and pursue process corrections. Delegate to the work group to recommend contractual penalties against the CCOs as appropriate

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Recommendations

Governor’s Rural Health Task Force Recommendations

• Hospitals develop Centers of Innovation to transition

from delivering moderate levels of care among all available resources to coordinating with neighboring facilities for greater efficiency and quality of care

• Leverage strength of ACOs and Clinically Integrated

Networks for rural hospitals.

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